SEP-0616-2022 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: DER 0 —�
Toxin of Quccnsbury
Permit Fee:$ �•
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensburV.net Septic Variance? Y O
Flood Zone? Y
Wetlands? Y N Reviewed
Project Location:
Tax Map #:
RESIDENCE INFORMATION:
Y B i Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (choose one) 0
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑
1191
PARCEL INFORMATION:
Topography - _ f Flat Rolling _❑Steep Slope ___ %_Slope_ _
Soil Nature ❑ Sand ❑ Loam ❑ Clay IN Ot er, explain:
J i
Groundwater At what depth? _v
Bedrock/Impervious material At what depth? Y. , b
Domestic Water Supply Municipal ❑ Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate:� per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size IQOQ gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub
System J Absorption field w/#2 stone Total length ft.; Each Tre'ncr Zq ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type: r
Holding Tank System Total required capacity? AM tank size ;
# of tanks—�L—
Septic Application Revised April 2021
:CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A lica t• <��
Napo
Mailing Address, C/S/Z: 10• Ot 3tl l(iIme'd evq!J� h�l�;On
► /� 7
Cell Pho e: d -� Land Line: �
Email: Z' ��GJr.CO)'►'J
• PrimarV Owner
Name(s):
Mailing Addr5s, C/S/Z: efiwo ,
Cell Phone: 'oil Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor: ,�/ T
Contact Name(s): i G ion
Contractor Trade: _ �I'h°�9✓ Cl1n ' �� �� � �� ���
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
•-- Engineer s
Name(s): tJ DC �aO d�
Mailing Address, C/S/Z: 9),.Y
Cell Phone: Land Line:
Email: A
Contact Person forCompliance in regards to this project: Y
Cell Phone: /f� 7Z.7 �J"/ U
0? Land Line:
Email: fig
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town approved electrical
inspection agency; 2. We will no longer allow systems to be covered until such time as an as-built plan is
received and approved. The installed system must match the septic layout on file—no exceptions. 3. As-
built drawings must be submitted prior to the inspection, if there has been a change to the submitted
plans. 4. If, for any reason, the building permit application is withdrawn, 30%of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100%of the fee is retained.
Declaration: Any permit or approval granted which is based upon or is granted in reliance upon any material
representation or failure to make a material fact or circumstance known by or on behalf of an applicant, shall be
void. I have read t egulations and agree to abide by these and all requirements of the Town of Queensbury
Sanitary Sewa D' pos O Hance.
nn �
PRINT NAME: U�1 i
i
SIGNATURE: DATE/ 1,-772
Septic Application Revised April 2021